Inframesocolic artery-first approach in laparoscopic ramps

Abstract

Purpose: In 2003, Strasberg described the radical antegrade modular pancreatosplenectomy. This procedure is specifically designed for the surgical treatment of cancer of the body/tail of the pancreas. It primarily aims to achieve low rates of circumferential margin involvement and oncologically adequate lymphadenectomy. Recently, an adaptation of the surgical technique to the laparoscopic context has been described. This approach accesses the retroperitoneal plane as the first manoeuvre. This inframesenteric approach ensures oncologically adequate margins and allows to take full advantage of the vision and features of minimally invasive surgery. Method: A 52 year old female patient was diagnosed with body-tail junction pancreatic adenocarcinoma. CT scan revealed a focal lesion of approximately 19 mm in the pancreatic tail. The patient received 4 cycles of neoadjuvant chemotherapy with FOLFIRINOX regimen. Following, laparoscopic RAMPS was performed as follows: Five trocars were placed. After opening theomental bursa to rule out peritoneal disease, an inframesenteric approach of the SMA was performed. By means of a ligament of Treitz approach, the left renal vein and the left-superior aspect of the SMA were dissected; also, and dividing the SMV, retroperitoneal dissection was further dissected. This approach rules out tumor infiltration into the SMA and also allows the early determination of the posterior dissection plane. Then, extended lymphadenectomy is performed. After dividing the neck of the pancreas and splenic vein, the retroperitoenal space -previously developed- is entered. This facilitates the completion of the procedure thus ensuring a negative tangential margin. Results: Operation was completed without any intraoperative complication. Surgical time was 360 minutes. Blood loss was less than 50 mL. Patient was discharged on fourth postoperative day and no postoperative complications were observed. 17 lymph nodes were identified on the pathological report, none of them were affected by carcinoma. No vascular nor lymphatic invasion was documented. All resection margins were tumor-free. Conclusion: The inframesocolic artery-first approach in laparoscopic RAMPS is a feasible and safe procedure. It confirms resectability early in the procedure, ensures and facilitates tumor free-margins, may reduce blood loss and reproduce optimal oncological results.